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Concrete Pumping Quote Request

Please complete this form as completely as you can. Please note that some questions will not apply to every company and so N/A is acceptable in those cases.

Name of Company:
Company Contact:
Address:

Phone:
Fax:
E-Mail:
Website:
Type of Business: Individual Partnership Joint Venture Corporation
Subchapter S Corp. Limited Liability Co.(LLC)
Number of Employees:
Number of Subcontractors:
Estimated Annual Receipts:
Estimated Annual Payroll:
Number of Claims Past 5 Years:
Description of Operations:
List all Contractors Licenses:
Business Owners
please list anyone with a controlling interest		 % of Ownership Yrs Concrete Pumping Experience
Current Insurance Policies Carrier Expiration Date
Liability:
Auto:
Property:
Workers Compensation:
Equipment:
Other (please specify):
Years in Business under above name:
Have you operated under any other name within the past 10 years?
If yes, is this business still active?
If yes, please provide name of business and describe it's operations
Does the Applicant/Business Owner currently owne any other Entities?
Does the Applicant/Business Owner (Applicant being the parent company) currently own any subsidiaries?
Is the Applicant/Business Owner currently listed as a Subsidiary of any other company?
If either of the above three questions is "Yes", provide answers to the questions in the section below
Entity/Subsidiary Name Operations General Liability Carrier Name
Is there an overlap in payroll between the Applicant/Business Owner and any of the Entities/Subsidiaries listed above? If yes, please explain.
Do any of the Entities/Subsidiaries listed above subcontract work to one another? If yes, please explain
Last Yr Sales Last Yr Payroll Next Yr Sales Est Next Yr Payroll Est
Concrete Pumping:
Guniting or Shotcrete Pumping:
Other (please describe) :
Do you perform work for:
New Home Construction?
New Condo / Townhouse Construction?
Residential Remodel?
What is you radius of operations (miles)?
Are your operators certified?
Are any of your operators under the age of 21?
Do any of your operator have less than 2 years experience?
Please list all states in which you operate:
Do you perform any of the following types of operations:
Mix in Transit?
Concrete, Gunite and/or Shotcrete Construction or Masonry (other than Concrete Pumping)?
Concrete, Gunite, Shotcrete and or Plaster Products Distrubution?
Concrete, Gunite, Shotcrete and or Plaster Products Manufacturing?
Concrete, Gunite, Shotcrete and or Plaster Products Installation?
Do you Rent Pumper Units, without Operator, TO OTHERS?
Do you Rent Equipment, other than Pumper Units, TO OTHERS?
Do you Subcontract Work Out to Others?
If yes, please answer the following questions regarding Subcontracting
What Type of Work:
Percentage of your total work Subcontracted to others:
Do you require all renters to provide you with evidence of Liability insurance, showing limits equal to or greater than your own limits?
Do you require all Subcontractors to add you as an Additional Insured onto their Liability Policy?
Do you require all Subcontractoras to indemnify you and/or hold you harmless?
Are you interested in Rental Reimbursement Coverage to cover the cost of rental equipment in the event of a loss?
Remarks:

Equipment List

Year Mfr Model Date Purch New/Used Value
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